Citation NR: 9707342
Decision Date: 03/07/97 Archive Date: 03/13/97
DOCKET NO. 93-27 432 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Cleveland,
Ohio
THE ISSUE
Entitlement to service connection for residuals of head
injury, including headaches.
REPRESENTATION
Appellant represented by: AMVETS
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
Artur F. Korniluk, Associate Counsel
INTRODUCTION
The veteran had active service from May 1951 to February
1955.
This case was previously before the Board of Veterans’
Appeals (Board) in October 1995, on which occasion it was
remanded to the Cleveland, Ohio Regional Office (RO) for
additional development. This case is now, once more, before
the Board for appellate review.
REMAND
Upon review of this case, there continues to exist some
question as to the exact nature and etiology of the veteran’s
claimed headaches, and various other residuals of his head
injury in service. In that regard, in November 1954, during
the veteran’s period of active military service, he was
brought to sick bay on a stretcher after having been hit on
the head by a ship’s hatch. Radiographic examination of the
veteran’s skull conducted at that time was negative. The
veteran was retained on the ward overnight for observation,
and returned to duty the following morning. The diagnosis
was laceration of the scalp; “injury slight.” The remainder
of the veteran’s service medical records are entirely
negative for any residual disability as a result of his head
injury.
On Department of Veterans Affairs (VA) medical examination in
September 1992 (almost 40 years following the veteran’s
separation from service), there was noted the presence of
hypesthesia of the veteran’s entire face, in conjunction with
a “drooping” of the left upper (eye)lid, “which was not
ptosis.” Additionally noted was a generalized hypesthesia of
both upper and lower extremities. The pertinent diagnosis
was posttraumatic headaches, “caused by the hatch injury to
his head in 1954.”
The Board notes that, on subsequent VA neurologic examination
in April 1996, the veteran’s cranial nerves were intact.
Motor and sensory testing were, likewise, unremarkable.
However, on subsequent VA neurologic examination
approximately one month later, there were noted headaches,
somewhat worse on the right than the left, accompanied by
paresthesia(s) associated with a visual prodrome. The
pertinent diagnosis was posttraumatic headaches. In the
opinion of the examiner, given the lack of any family history
of headaches, or any history of such headaches prior to the
veteran’s inservice accident, the veteran’s headaches were
most likely of a posttraumatic nature. Additionally noted
was that the visual and sensory prodromes from which the
veteran suffered were “part and parcel” of his classic
migraine headaches.
As of the time of the veteran’s most recent VA neurologic
examination in July 1996, he complained of “occasional
paresthesias” which occurred during the visual prodrome which
preceded his headaches. The pertinent diagnosis was
posttraumatic headache, “based on the veteran’s history, that
there were no headaches prior to the accident, and that there
was no family history to support a congenital headache
disorder.”
The Board observes that, at the time of the prior remand in
October 1995, the veteran was held to have raised the issue
of service connection not only for headaches, but also for
“hypesthesia” as the residual of his inservice head trauma.
In light of the aforementioned, the Board is compelled to
conclude that, at present, it is unclear whether the veteran
does, in fact, suffer from a chronic headache disorder and/or
hypesthesia, and, if so, whether such disabilities are the
result of his inservice injury. Accordingly, the case is,
once again, REMANDED to the RO for the following:
1. Any pertinent VA or other inpatient
or outpatient treatment records,
subsequent to July 1996, the date of the
veteran’s most recent VA examination,
should be obtained and incorporated in
the claims folder. The veteran should be
requested to sign the necessary forms for
release of any private medical records to
the VA.
2. The veteran should then be afforded
an additional VA neurologic examination,
to include all necessary studies, in
order to more accurately determine the
exact nature and etiology of his claimed
headache disorder and/or accompanying
hypesthesia. This examination should be
conducted by a neurologist who has not
heretofore seen or examined the veteran.
All pertinent symptomatology and findings
should be reported in detail. Following
examination, the examiner should
specifically comment as to whether the
veteran currently suffers from a chronic
headache disorder, or any other residuals
(including hypesthesia) of head trauma,
and whether such residuals, if present,
are as likely as not the result of the
veteran’s inservice head trauma, as
opposed to some other, postservice on-
the-job injury. In that regard, the
attention of the examiner is drawn to a
statement of the veteran’s private
physician dated in June 1993, noting
various “industrial injuries” since July
1979. All such information and opinions,
when obtained, should be made a part of
the veteran’s claims folder. The claims
folder and a copy of this REMAND must be
furnished to the examining neurologist
prior to his evaluation in order to
facilitate the study of the case.
Following completion of the above actions, the RO should
review the evidence, and determine whether the veteran’s
claim may now be granted. If not, the veteran and his
representative should be provided with an appropriate
supplemental statement of the case, and given an ample
opportunity to respond. The case should then be returned to
the Board for further appellate review.
In this REMAND of the claim for further development, the
Board does not intimate any opinion as to the ultimate
determination warranted. No action is required of the
appellant until he receives further notice.
S. F. SYLVESTER
Acting Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741
(1994), permits a proceeding instituted before the Board to
be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Veterans Appeals. This remand is in the nature of a
preliminary order and does not constitute a decision of the
Board on the merits of your appeal. 38 C.F.R. § 20.1100(b)
(1995).
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